<div id="postResults"></div>
{clni_form}
<input type="submit" value="Update" />
<div style="clear: both;"></div>
<br />
<table>
<tr>
<td>
<tr>
<td><b>Previous Illness</b>:</td>
<td>
{input type="string" name="previous_illness_name"}
</td>
</tr>
<tr>
<td>
<b>Status</b>:</td>
<td>
{input type="radio" name="previous_illness_status" value="open" options="Open" display="horizontal"}
{input type="radio" name="previous_illness_status" value="closed" options="Closed" display="horizontal"}
</td>
</tr>
<tr>
<td><b>Year</b>:</td>
<td>{input type="date" name="previous_illness_year"}</td>
</tr>
<tr>
<td><b>Comment</b>:</td>
<td>
{input type="string" name="previous_illness_comment" size="40"}
</td>
</tr>
</table>
</form>
